=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518632629
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REBEKAH MARIE COUNTRYMAN MA, LPC, LAC, AADC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2021
-----------------------------------------------------
Last Update Date | 07/12/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 261 CALHOUN ST STE 250
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29401-1371
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-867-8431
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 913 DIANA ST
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29407-6401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-239-7067
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 535
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 8270
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------